Patients and clinicians are overcoming insurance obstacles and securing coverage using the resources of Cover My Mental Health.
We are delighted to share their stories below.
To share your stories, email us at stories stories@covermymentalhealth.com. Thanks.
As reported in Psychiatric News:
Karen Pierce, M.D., a Chicago-based child and adolescent psychiatrist, was treating a teenage girl with mild obsessive-compulsive disorder whose symptoms became severe following an infection.
“She was washing her hands raw and had to drop out of school,” Pierce said. “She didn’t want to go into a hospital but could do daily cognitive behavior therapy and exposure therapy. The insurance company said no to daily therapy, allowing only once a week.”
Pierce gathered evidence about the efficacy of exposure therapy, wrote a letter to the insurance company, and was able to get the company to approve therapy three times a week. “This girl got better within six weeks, was able to go back to school, and eventually tapered the therapy to once a week,” said Pierce, who is a member of APA’s Council on Advocacy and Government Relations. “And she didn’t have to be hospitalized.”
The insurance reviewer on her case wasn’t a child psychiatrist and so may not have appreciated the special considerations involved in treating a teenager. “I was able to talk about the developmental issues involved in missing her peer group and missing out on progression in school,” Pierce said, “and was able to make the case that this young woman really needed the outpatient therapy. And it worked.”
Pierce told Psychiatric News that learning how to write medical necessity letters on behalf of her patients has made a difference in her practice and in their lives. While insurance companies have their own narrow definition of medical necessity based on criteria they develop outside of public scrutiny, a medical necessity letter written by a clinician can draw on evidence-based guidelines developed by APA, the American Academy of Child and Adolescent Psychiatry, the American Society of Addiction Medicine, and other professional societies.
“When you can talk back to an insurance company, you can really get the care your patient needs,” Pierce said. “It’s impressive to see it happen.”
A Chicago-based psychiatrist encountered insurance obstacles to the appropriate selection of medication for an adolescent patient.
“Nearly all my adolescent patients who I treat for ADHD have good success with oral medications, though not all. One of my patients experienced side effects, sensory issues, and therefore poor adherence with oral medications, and so it was clearly appropriate to pursue another delivery format, specifically, a transdermal patch.
“Time was of the essence as we needed stabilization before the start of school in fall. Anticipating an inevitable denial and the subsequent multi-step appeal process, which typically consumed hours of administrative time away from clinical duties, we prepared a medical necessity letter, using the Cover My Mental Health template.
“The letter detailed the patient’s diagnosis, functional impairments, and specific barriers to oral medication. It highlighted the mental health challenges that made oral stimulant medications unsuitable and emphasized that the transdermal delivery system was medically necessary to support consistent treatment, symptom management, and improved daily functioning.
“Pleasantly, the process was streamlined, resulting in approval less than 12 hours and securing insurance coverage for the medication. This allowed the patient to begin the treatment promptly, saved the staff and clinical team significant time by avoiding multiple appeals, and provided the insurance party with the necessary information to understand and process the request. Triple win for all!”
Dr. Mojgan Makki
Psychiatry Studio – https://www.psychiatrystudio.com/
Chicago
At a Chicago-area co-occurring disorders clinic, an addiction medicine specialist faced a significant insurance challenge for her patient. Actually, multiple challenges… none of which were resolving and all at significant risk to the patient. Further delays in initiating treatment may hinder a patient’s ability to reduce alcohol consumption and increase their risk of progressing to cirrhosis.
The required treatment was clear: a Vivitrol injection for alcohol use disorder.
The insurance obstacles were many:
Here’s the story from the clinician about what happened next:
“We have had difficulties getting this medication approved for a long time. Several of their fax numbers did not work so the appeals were not getting received by the insurance company. The injection was not covered on the basis of the patient not being fully abstinent from alcohol. ASAM and the FDA agree that the patient should not be acutely intoxicated at the time of the injection, but a minimum time period of abstinence prior to the injection is not required. This long-acting injectable can support patients in achieving and sustaining abstinence by reducing cravings and the reinforcing effects of alcohol.
“Using a medical necessity letter based on the template from www.covermymentalhealth.org, I provided the reasonings for why a patient does not have to be fully abstinent, but just stable as the medication is used to support recovery. Since the appeals did not go through, and the 30 days had passed since the original denial, I submitted a second PA [prior authorization request] and attached clinical documentation and the medical necessity letter to it and had success!
“Unfortunately, now there is a large copay because the patient has not hit their deductible yet, but we are working on figuring that out.”
“I was in a car accident in February. I had previously dealt with significant car-related anxiety, to the point where I found it difficult to be a passenger in the car because I was constantly flinching for fear of getting in an accident.
“My insurance company offered $5000 of medical covering for the accident, and I wanted to spend some of that on mental health services to deal with my anxiety post-accident, but I was not sure if mental health would be covered.
“Cover My Mental Health provided resources including a template letter of medical necessity that I could give to my mental health care team in order to get services covered. The letter detailed the reasons why mental health services were necessary following the accident and outlined a treatment plan. I sent the letter to my insurance company, and they reimbursed me for mental health services, no questions asked!”
“In my work with a young adult who presented complex co-morbidity, I soon recognized that the insurance support available for residential care or intensive outpatient treatment would be insufficient. She and her family were facing yet again another round of protracted battles to eke out meager payments, if any at all. My patient and her family had plenty on their plate and dealing with their insurer was surely more than they needed at that time.
“After receiving the anticipated and unwarranted denial deeming her care “not medically necessary” treatment, I knew that the insurer could not have the last word. My patient, and others like her, deserved better.
“I documented my clinical assessment using the template medical necessity letter provided in a Journal of Psychiatric Practice article authored by Joe Feldman (president of Cover My Mental Health), Dr. Eric Plakun (Medical Director and CEO at Austen Riggs Center) and Mark DeBofsky (litigator and expert in health insurance at DeBofsky Law).
“That medical necessity letter made all the difference for my patient, her family, and for me as the clinician responsible for his care. The insurer reversed their unsubstantiated denial, approving the required care, and relieved the family of an unnecessary burden.”
Michael Groat, PhD
Associate Professor of Psychiatry and
Behavioral Neuroscience and President/CEO
Lindner Center of Hope
“Treating individuals with OCD is deeply rewarding. As we continue to expand our understanding of the condition’s complexities, advances in evidence-based therapies give both clinicians and patients real hope,” shared a clinician who leads a specialized OCD practice in Texas. “Yet despite progress in treatment, our patients and their families still face significant challenges-especially when it comes to insurance coverage.”
Due to the scarcity of in-network providers with specialized training in OCD, many patients at this clinic must work with their insurers to secure waivers or “single case agreements” (SCAs), allowing them to access out-of-network care as if it were in-network.
Here’s what that looks like in practice:
“Several of our patients were unable to find qualified OCD providers within their insurance networks. With persistence, they were able to secure SCAs that allowed the clinic to bill insurance directly at a contracted rate – one that reflects the expertise required for effective OCD treatment. At first, everything seemed to be going smoothly.
“However, after submitting claims under these agreements, we ran into problems. Payments were delayed, inaccurately processed, or denied altogether. Repeated follow-up calls yielded little progress.”
That’s when the clinic learned about Cover My Mental Health during a conference presentation.
“We were introduced to the idea of filing a formal complaint with the insurer – a process we hadn’t fully explored. On our next call, after another round of evasions, we informed the insurer of our intent to file a formal complaint regarding their handling of the claims.
“The response was immediate. Suddenly, we were told a complaint wouldn’t be necessary and that payment would be issued right away.”
This experience highlights the power of formal insurer complaints as a tool for holding insurers accountable and ensuring patients receive the coverage they’re entitled to.
“Cover My Mental Health provided us with practical knowledge that helped our patients access care and our clinic receive appropriate reimbursement. It’s a resource we’re grateful to have discovered.”
Cover My Mental Health NFP provides education and guidance with respect to dealing with denied health insurance claims and other obstacles to receiving mental health care. Cover My Mental Health does not provide legal services or legal advice with respect to those or any other matters. Each individual should review his/her/their insurance policy or plan document thoroughly. Questions and concerns about legal rights and obligations under such plans, policies or applicable law should be directed to a qualified attorney who can provide counsel on alternative steps to ensure all benefits to which an insured is entitled are timely provided.
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